Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Study on Mongolia's Foreign Strategies toward China and Russia: Viewed from the Concept of Hedging (1994-2012)

蒙古地處於中俄之間的內陸小國，因其特殊的地理位置，不管在國內外政治、經濟、國家安全等方面往往都受到兩強鄰的影響。自1921年蒙古獨立後，蒙古積極與蘇聯合作建立「準同盟」關係。至第二次世界大戰結束後，蒙古進一步採取對蘇的「一邊倒」戰略。蘇聯解體後，蒙古國內政局發生劇烈變化，導致其對外戰略也進行根本性調整，開始實施「不結盟、多支點」的對外政策。蒙古透過其「避險」策略展現出務實和靈活的特色。一方面基於歷史傳統、地緣政治和經濟實惠的原因，優先發展與中、俄兩大鄰國的關係；另一方面，為避免在戰略上受制於中、俄、因此致力於發展與西方，尤其是美國以及國際組織之間的全面合作關係，努力在各大國相互競爭和制約的「漩渦」中力保蒙古本國的安全、穩定和發展。Mongolia is a landlocked country between China and Russia, either external or internal politics, economics and security are always affected by these both countries. Since Mongolia became independent in 1921, it started to develop “quasi-alliance” relations with the Soviet Union. Until the Second World War ended, Mongolia and Soviet Union became close allies. After the end of the Cold War, Mongolia polity was facing an acute tranformation. Mongolia started to develop a new “non-aligned, multi-pillar” foreign policy to guarantee its politics, economic and security. By taking the “hedging”strategy, Mongolia had showed the characters of pragmatism and flexiblility. On the one part, based on the historical traditional, geo-political and economic benefits, Mongolia needs to maintain friendly relations with Russia, China; on the other part, to avoid being controled by China and Russia, Mongolia need to cooperate comprehensively with U.S, East Asian countries, and international organizations, to protect its national security and development.目錄 第一章 緒論 1 第一節 研究動機與目的 1 第二節 文獻探討 4 第三節 研究途徑與方法 14 第四節 研究範圍與限制 18 第五節 研究架構與章節安排 20 第二章 蒙古外交政策的演變 25 第一節 蒙古特殊的地緣位置 25 第二節 與蘇聯「準同盟」的戰略 29 第三節 與蘇聯全面結盟「一邊倒」戰略 33 第四節 「不結盟、多支點」的外交政策 38 第五節 小結 42 第三章 中俄對蒙古的威脅 47 第一節 中俄綜合實力 48 第二節 蒙古與中俄地緣的鄰近性 59 第三節 中俄的進攻力量 60 第四節 中俄侵略之意圖 66 第五節 蒙古政治精英和社會的意向 69 第六節 小結 73 第四章 蒙古的避險策略 77 第一節 發展有限度的自我防衛能力 77 第二節 與中俄的交往政策 81 第三節 與潛在友邦簽署低承諾合作協議 99 第四節 國際組織及國際論壇的互動 117 第五節 小結 128 第五章 蒙古避險策略的中俄回應 133 第一節 中國的回應 133 第二節 俄羅斯的回應 138 第三節 蒙古避險策略的挑戰 141 第四節 小結 143 第六章 結論 147 第一節 研究發現 147 第二節 未來發展 150 參考書目 153 表目錄 表4-1 中蒙兩國高層領導人互訪事蹟時間表 83 表4-2 2010及2011年1-7月蒙古出口數據表（單位：千美元） 87 表4-3 2010及2011年1-7月蒙古進口數據表（單位：千美元） 88 表4-4 俄蒙兩國高層領導人互訪事蹟時間表 93 表4-5 美蒙兩國高層領導人互訪事蹟時間表 101 表4-6 印蒙的雙邊貿易數據表（單位：百萬美元） 115 表4.7 蒙古參加聯合國維和行動表 120 圖目錄 圖1-1 研究架構圖 23 圖4-1 外國對蒙古直接投資數據圖 9

Study on Mongolia’s Foreign Strategies toward China and Russia: Viewed from the Concept of Hedging (1994-2012)

蒙古地處於中俄之間的內陸小國，因其特殊的地理位置，不管在國內外政治、經濟、國家安全等方面往往都受到兩強鄰的影響。自1921年蒙古獨立後，蒙古積極與蘇聯合作建立「準同盟」關係。至第二次世界大戰結束後，蒙古進一步採取對蘇的「一邊倒」戰略。蘇聯解體後，蒙古國內政局發生劇烈變化，導致其對外戰略也進行根本性調整，開始實施「不結盟、多支點」的對外政策。蒙古透過其「避險」策略展現出務實和靈活的特色。一方面基於歷史傳統、地緣政治和經濟實惠的原因，優先發展與中、俄兩大鄰國的關係；另一方面，為避免在戰略上受制於中、俄、因此致力於發展與西方，尤其是美國以及國際組織之間的全面合作關係，努力在各大國相互競爭和制約的「漩渦」中力保蒙古本國的安全、穩定和發展。Mongolia is a landlocked country between China and Russia, either external or internal politics, economics and security are always affected by these both countries. Since Mongolia became independent in 1921, it started to develop “quasi-alliance” relations with the Soviet Union. Until the Second World War ended, Mongolia and Soviet Union became close allies. After the end of the Cold War, Mongolia polity was facing an acute tranformation. Mongolia started to develop a new “non-aligned, multi-pillar” foreign policy to guarantee its politics, economic and security. By taking the “hedging”strategy, Mongolia had showed the characters of pragmatism and flexiblility. On the one part, based on the historical traditional, geo-political and economic benefits, Mongolia needs to maintain friendly relations with Russia, China; on the other part, to avoid being controled by China and Russia, Mongolia need to cooperate comprehensively with U.S, East Asian countries, and international organizations, to protect its national security and development.目錄 第一章 緒論 1 第一節 研究動機與目的 1 第二節　文獻探討 4 第三節　研究途徑與方法 14 第四節　研究範圍與限制 18 第五節　研究架構與章節安排 20 第二章 蒙古外交政策的演變 25 第一節 蒙古特殊的地緣位置 25 第二節　與蘇聯「準同盟」的戰略 29 第三節　與蘇聯全面結盟「一邊倒」戰略 33 第四節　「不結盟、多支點」的外交政策 38 第五節　小結 42 第三章 中俄對蒙古的威脅 47 第一節 中俄綜合實力 48 第二節 蒙古與中俄地緣的鄰近性 59 第三節 中俄的進攻力量 60 第四節　中俄侵略之意圖 66 第五節　蒙古政治精英和社會的意向 69 第六節　小結 73 第四章 蒙古的避險策略 77 第一節　發展有限度的自我防衛能力 77 第二節　與中俄的交往政策 81 第三節 與潛在友邦簽署低承諾合作協議 99 第四節 國際組織及國際論壇的互動 117 第五節 小結 128 第五章 蒙古避險策略的中俄回應 133 第一節　中國的回應 133 第二節　俄羅斯的回應 138 第三節 蒙古避險策略的挑戰 141 第四節　小結 143 第六章 結論 147 第一節　研究發現 147 第二節　未來發展 150 參考書目 153 表目錄 表4-1　中蒙兩國高層領導人互訪事蹟時間表 83 表4-2　2010及2011年1-7月蒙古出口數據表（單位：千美元） 87 表4-3　2010及2011年1-7月蒙古進口數據表（單位：千美元） 88 表4-4　俄蒙兩國高層領導人互訪事蹟時間表 93 表4-5　美蒙兩國高層領導人互訪事蹟時間表 101 表4-6　印蒙的雙邊貿易數據表（單位：百萬美元） 115 表4.7　蒙古參加聯合國維和行動表 120 圖目錄 圖1-1　研究架構圖 23 圖4-1　外國對蒙古直接投資數據圖 9

In search of a reciprocal relationship in dessert cafés: linking customer perceived innovativeness to value co-creation behavior

Abstract This study examined a conceptual model encompassing perceived innovativeness, perceived values, attitude, and customer value co-creation behavior in the context of dessert cafés. An online survey was conducted with customers of dessert café chains based in Malaysia. The results indicated that menu innovativeness had the highest contribution to perceived innovativeness, followed by experiential innovativeness. The study found that perceived innovativeness improved the value of money, evoked positive emotions, and enhanced social image. In highly innovative dessert cafés, positive emotions led to a positive attitude and, in turn, increased willingness to co-create value. This study provides valuable insights for dessert café businesses by emphasizing the need to foster innovation and create emotionally satisfying experiences to enhance customer engagement in co-creation activities

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe